Is increased life expectancy a measure of better health? Or does it simply measure the success of medical technologies in keeping the machinery of the body operating?
I was reminded of these questions last week when I read “How are Canadians Really Doing? The First Report of the Institute of Wellbeing.” The Institute is an official arm of the Canadian government set up to measure the health of Canadians. It maintains the Canadian Index of Wellbeing. This is a good idea that has its problems.
Like the idea of Gross National Happiness, the Canadian Index of Wellbeing attempts to avoid the absurdities of indexes such as Gross National Product that measure the quality of life using exchange values instead of use values—use values being the actual things that bring people joy, sorrow, and the rest of the chunks in life’s soup. The purpose of the Index of Wellbeing is to capture the quality of life experienced by the Canadian people so that the government can take actions that will make Canadian life better in a meaningful way.
The use values that go into calculating the Index were identified based on interviews with actual Canadians who were asked about what matters to them. The index includes measures for art, culture, and recreation; civic engagement; community vitality; education; sustainability of natural environments; health; living standards; and how people use their time. The people at the Institute put this all in a statistical pot, cooked it, and found that while the Canadian Gross National Product rose between 1994 and 2004, the wellbeing index remained stagnant. What this tells me is this: more stuff (and even better stuff) does not make life better.
The index has plenty of limitations. For example, the category of health has been lost to medicine: it isn’t about health but access to medical services and the quality of those services. It’s sad that the Institute is unable to use the word health because it has been taken hostage by the medical system. Instead, they must use wellbeing—in my observation, a word that is more or less synonymous with health but that perhaps suggests greater subjectivity, spirituality, and feel goodness. And if you think this is only about a word, consider the fight over the word marriage.
The two principal limitations I see to health indexes such as the Canadian Index of Wellbeing are that they are institutionalized and that they are generalized abstractions. As an instrument of institutions, health indexes are subject to institutional laws of motion that have principally to do with power: can you decide on and get what you want. Good (and for that matter bad) intentions aside, the needs of the institution are not the needs of specific people.
Health indexes are general and abstract because they take the specific conditions of each unique person in the population and abstract from those specific people in order to generalize about the population as a whole. Based on those abstract, generalized conditions, institutions do what they do to alter general conditions. Whether wellbeing actually improves and for whom it improves is, as we are all aware, a much messier business. I think immediately of the tortured politics concerning the mortgage crisis and legislation for so-called universal health care.
A measure of health that is institutionalized and an abstract generalization is not in itself a bad thing. But it will almost certainly lead to perverse effects unless it is a living element in the lives of actual people with specific capacities in specific circumstances deciding on and working to get what they need. In other words, a usable measure of health needs to be about the powers of actual people.
We often say that health isn’t the absence of disease. Health is the capacity to live a full, rich life. Another word for capacity is power. And health is not a single power, but a collection of powers, from the biological to the political. The power to move, the power to nourish yourself, the power to heal, the power to adapt to your environment, the power to change your environment. Specific to you. So for me the critical issue is not how to measure those powers in an index so some distant institution can allocate funds for this project or that. For me, the critical issue is how each unique person can increase those powers and put them to good use.
